Melissa's Good Timin Jackpot, January 17, 2021 Entry Form -

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Rider's Name
First Name
Last Name
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Emailrequired please
example@example.com
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Address - OptionalThis is for office if you leave before payout so winnings can be mailed.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Numberoptional
Area Code
Phone Number
5
Entry fees & classes

$4 Exhibition

NO PEE WEE

Open 4D - entry fees $35 ($5 goes toward added money)

Youth 2D - $25 for all - 17 years and younger - roll over only

Youth has to have at least 5 entries before 2D payout (1 second split); otherwise, 1st place wins all.

Seniors 2D - 40 + years - roll over only - have to have, at least, 5 entries before 2D payout (1 second split); otherwise, 1st place wins all.
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ENTRY BOX - Please state Class and horse's name- Open 4D; Youth 2D (17 & younger) is roll over only for this particular show; and/or Seniors (40+ years) 2D. If riding multiple horses, please do the same thing for the next horse. Each contestant (RIDER) should fill out this form one time and specify each horse. Please do NOT put multiple contestant's (RIDERS) names on one submission.Second, with pre entering, you get the privilege of requesting your entry number, please give the entry number you would like, if running open (however, this number cannot be guaranteed). Please give 3 numbers to choose from and you will, hopefully, get the earliest one available. Third, if you are running Youth, please state whether you are running physically the event or rolling over the time from the open (if running open too). Fourth, if riding multiple horses, please state which horse's you want to run in order (and in each class). Please note: If you pre enter and pre pay entries and prepay for exhibitions wanted with paypal and/or credit card, you do not have to worry about coming up to the announcer's stand. Just shoot me a text at 863-398-6802 confirming you are there. Be sure you give me your name(s) so I know who the text is from. Your exhibitions will be written down on a piece of paper with the person at the gate.
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How many Exhibition
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2
3
4
5
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10
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Birth Date:This is for Youth Riders: Must be 17 or under as of January 2020
Month
Day
Year
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Payment TypeYou can either prepay entries or pay at show. If pre pay, member rate is given for open barrels. An email will be sent to you with your total and the options of how to pay. A small fee may apply depending on how prepay.
Would like to PrePay entries
Pay at show
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In accepting this entry, the applicant hereby releases and discharges the Florida Equine Athlete, all officers, personnel, representatives, employees, agents, Melissa Greer Ph.D., host arenas, arena owners, and family members from liability, loss, claims, damages, and/or expenses for injuries or death to person, animal, property, family member(s), friends, or anyone affiliated with applicant, reputations, or financial conditions as a results of, or in any way, relating to applicant’s participation or nonparticipation in FEABRA sanctioned event whether caused by negligence, arena conditions, and/or by the conduct of the Florida Equine Athlete or arena hosts, owners, officers, etc.PLEASE BE SURE TO MARK THE BOX BELOW.
I have read, understood, and accepted the above waiver statement for entry and participataion of this show.
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Signature For Youth entries, this form MUST be signed by parent or guardian; I will need a parent or guardian to verify this permission at the day of the show.
Clear
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Date signed
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Once you submit your application, I will send you a confirmation of entry. If you do NOT receive confirmation, please shoot an email to floridaequineathlete@gmail.com to make sure it was received.

See you January 17, 2021 and please drive safely. God Bless

Thank you for coming! :)
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